CBT is shown to be Effective for Body Dysmorphic Disorder

There are few effective treatments for body dysmorphic disorder (BDD) and a pressing need to develop such treatments. We examined the feasibility, acceptability, and efficacy of a manualized modular cognitive-behavioral therapy for BDD (CBT-BDD). CBT-BDD utilizes core elements relevant to all BDD patients (e.g., exposure, response prevention, perceptual retraining) and optional modules to address specific symptoms (e.g., surgery seeking).

Thirty-six adults with BDD were randomized to 22 sessions of immediate individual CBT-BDD over 24 weeks (n = 17) or to a 12-week waitlist (n = 19). The Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS), Brown Assessment of Beliefs Scale, and Beck Depression Inventory–II were completed pretreatment, monthly, posttreatment, and at 3- and 6-month follow-up. The Sheehan Disability Scale and Client Satisfaction Inventory (CSI) were also administered. Response to treatment was defined as ? 30% reduction in BDD-YBOCS total from baseline. By week 12, 50% of participants receiving immediate CBT-BDD achieved response versus 12% of waitlisted participants (p = 0.026). By posttreatment, 81% of all participants (immediate CBT-BDD plus waitlisted patients subsequently treated with CBT-BDD) met responder criteria. While no significant group differences in BDD symptom reduction emerged by Week 12, by posttreatment CBT-BDD resulted in significant decreases in BDD-YBOCS total over time (d = 2.1, p < 0.0001), with gains maintained during follow-up. Depression, insight, and disability also significantly improved. Patient satisfaction was high, with a mean CSI score of 87.3% (SD = 12.8%) at posttreatment. CBT-BDD appears to be a feasible, acceptable, and efficacious treatment that warrants more rigorous investigation.

Wilhelm, S., Phillips, K. A., Didie, E., Buhlmann, U., Greenberg, J. L., Fama, J. M., Keshaviah, A., … Steketee, G. (2014). Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial. Behavior Therapy, 45, 3, 314-327.

Telephone-administered CBT Versus Face-to-Face CBT for Depressed Patients with Co-occurring Problematic Alcohol Use in Primary Care

This secondary analysis of a larger study compared adherence to telephone-administered cognitive-behavioral therapy (T-CBT) vs. face-to-face CBT and depression outcomes in depressed primary care patients with co-occurring problematic alcohol use. To our knowledge, T-CBT has never been directly compared to face-to-face CBT in such a sample of primary care patients. Participants were randomized in a 1:1 ratio to face-to-face CBT or T-CBT for depression. Participants receiving T-CBT (n = 50) and face-to-face CBT (n = 53) were compared at baseline, end of treatment (week 18), and three-month and six-month follow-ups. Face-to-face CBT and T-CBT groups did not significantly differ in age, sex, ethnicity, marital status, educational level, severity of depression, antidepressant use, and total score on the Alcohol Use Disorders Identification Test. Face-to-face CBT and T-CBT groups were similar on all treatment adherence outcomes and depression outcomes at all time points. T-CBT and face-to-face CBT had similar treatment adherence and efficacy for the treatment of depression in depressed primary care patients with co-occurring problematic alcohol use. When targeting patients who might have difficulties in accessing care, primary care clinicians may consider both types of CBT delivery when treating depression in patients with co-occurring problematic alcohol use.

Kalapatapu, R. K., Ho, J., Cai, X., Vinogradov, S., Batki, S. L., & Mohr, D. C. (2014). Cognitive-Behavioral Therapy in Depressed Primary Care Patients with Co-Occurring Problematic Alcohol Use: Effect of Telephone-Administered vs. Face-to-Face Treatment-A Secondary Analysis. Journal of Psychoactive Drugs, 46, 2, 85-92.

CBT/MET Therapy Helps Improve Symptoms in Comorbid MDD/AUD Adolescents

A recent, two-year acute phase trial published in Addictive Behaviors found both manual-based cognitive behavior therapy (CBT) and motivation enhancement therapy (MET) to be beneficial treatments for adolescents suffering from both major depressive disorder (MDD) and alcohol use disorder (AUD). This was the first controlled study to compare CBT/MET with fluoxetine or placebo versus naturalistic care (control group), among adolescents with comorbid MDD/AUD.

Participants included 50 adolescents (ages 15-20) who met DSM-IV criteria for AUD and MDD. Qualified and trained masters level staff delivered nine sessions of manual-based CBT/MET, coupled with either fluoxetine (SSRI) or a placebo pill, to participants in the experimental condition. The Hamilton Rating Scale for Depression (HAM-D-27) and the Beck Depression Inventory (BDI) were used to assess depressive symptoms. The timeline follow-back method (TLFB), a tool used to measure controlled drinking, assessed drinking behavior.

Participants in the experimental condition who received CBT/MET demonstrated superior outcomes to the control group who did not receive any psychological intervention. Furthermore, no differences were noted between participants who received CBT/MET and fluoxetine versus CBT/MET and a placebo. These findings suggest that CBT/MET may be most efficacious for the treatment of comorbid MDD/AUD.

Cornelius, J.R., et al. (2011). Evaluation of cognitive behavioral therapy/motivational enhancement therapy (CBT/MET) in a treatment trial of comorbid MDD/AUD adolescents. Addictive Behaviors, 36(8), 843-848.

Evaluation of a DVD-Based Self-Help Program in Highly Socially Anxious Individuals – Pilot Study

A recent study published in Behavior Therapy found a CBT-oriented DVD-based self-help program (SHP), to be a potential treatment option for those with nonclinical degrees of social anxiety. Social anxiety disorder is described as a constant fear of particular social or performance situations coupled with acting in an embarrassing manner in those situations. The current study sought to evaluate the effectiveness of CBT-oriented DVD-based SHP supplemented by therapeutic assistance. The participants in the current study suffered from subthreshold social anxiety, which if not treated could evolve into social anxiety disorder as diagnosed in the DSM-IV. Participants had access to therapists via phone, email, or in-person sessions, in addition to the SHP.

Following several self-report questionnaires and an interview, twenty-four participants were selected to participate in the study. Twelve participants were assigned to the control group and were placed on a wait-list while the remaining twelve were given the SHP. Both groups completed self-report measures before and after the intervention. The experimental group underwent an eight-week trial program during which time they viewed guided lessons and were subsequently given homework assignments (e.g., approaching a stranger and asking for the time.) Participants then emailed their therapist a summary of their homework assignment. This helped researchers ensure that participants were truly completing the program and understanding the material presented to them.

Results demonstrated that participants in the experimental group showed improvement in their scores on the self-report assessments. Out of the twelve participants in the experimental group, only one withdrew during the eight-week session for unknown reasons. This low attrition rate may suggest that the program was well-received. The researchers concluded that CBT-oriented DVD-based SHPs supplemented by therapeutic assistance could benefit those with social anxiety symptoms.

Mall, A.K., et al. (2011). Evaluation of a DVD-based self-help program in highly socially anxious individuals—Pilot study. Behavior Therapy, 42, 439-448.

First Comparative Study of Early and Delayed CBT Interventions for PTSD

A recent and first comparative study of early and delayed cognitive behavior therapy (CBT) interventions for PTSD found that prolonged exposure (PE), cognitive therapy (CT), and delayed PE prevent chronic PTSD in recent survivors. This study published in the Archives of General Psychiatry used equipoise-stratified randomization with trauma survivors who were recruited from Hadassah Hospital in Jerusalem. Adult trauma survivors were initially screened via telephone to ensure that they met DSM-IV criteria for PTSD. Adults (516) who met criteria were randomly assigned to receive treatment in a prolonged exposure (PE) group, a cognitive therapy (CT) group, double blind comparison of treatment with escitalopram (SSRI) or placebo groups, and a control wait-list group. Of the 756 adults who did not meet DSM-IV criteria, 296 of them accepted an invitation to receive clinical assessment.

The participants were evaluated following early interventions at 5 months and assessed again at 9 months. PE and CT treatment sessions were recorded and evaluated by CT experts. The Clinician-Administered PTSD Scale (CAPS) was used to measure the presence of PTSD at 5 and 9 months following treatment. Results showed that PE, CT, and delayed PE treatments were effective in lowering the rates and symptoms of PTSD in participants. Furthermore, there was no significant difference between the presence of PTSD in participants who received PE or CT and delayed PE treatment. This suggests that delaying PTSD interventions may not pose a threat to treatment outcomes. There was also no difference in improvement between the groups who received the SSRI versus placebo pills.

Since this was the first comparative study of early and delayed PTSD interventions, the researchers recommend replication studies to test for reliability. They also propose that future research focus on more simple CBT techniques to determine how those methods play a role in preventing PTSD. Finally, the lack of improvement from pharmacological treatment with escitalopram necessitates further evaluation and replication with larger samples.

Shalev, A.Y., Ankri, Y., Israeli-Shalev, Y., Peleg, T., Adessky, R., & Freedman, S. (2011). Prevention of posttraumatic stress disorder by early treatment. Arch Gen Psychiatry.

Using CBT to Target Body Image Issues in Female College Smokers

A recent study showed that using CBT techniques to target body image issues among female smokers in smoking cessation intervention programs can help lower their smoking rates. High smoking rates and the health risks associated with smoking are a serious concern. An alarming twenty-two to thirty-four percent of college students smoke cigarettes. Previous research has shown that smoking rates in some female college students are related to their body image beliefs. This research used the cognitive pathway of body image and smoking to explain how females’ schemas of their body image serve as a foundation for smoking. These previous studies suggest that when females ruminate about their weight, they develop a cognitive bias about their body, which leads them to use smoking as a method for weight loss.

In the current study published in Behavior Modification researchers created two intervention programs for female college students to help them decrease the number of cigarettes they smoked. Twenty-four female college students were recruited to participate in an eight-week cognitive behavior smoking cessation program. They were placed into either an internet smoking session and body image group or an internet smoking session and exercise group. Both groups participated in a an hour long smoking cessation workshop which involved cognitive behavior therapy techniques (e.g., goal setting and skill building) followed by either a body image workshop or an exercise class. In addition, an internet site called Blackboard was used for group discussions and to distribute handouts.

Smoking, body image, and weight concerns were assessed using questionnaires following the intervention. Results showed that the smoking cessation rates for those who participated in the internet smoking session and body image group were greater than the rates for those who participated in the internet smoking session and exercise group. This research supports the hypothesis that body image schemas affect smoking habits in female college students.

In terms of limitations, the current study used a small sample size, lacked a control group, and used web-based instead of face-to-face group discussions. All of the participants involved in this research recommended the program to others, and they suggested that future studies incorporate face-to-face programs to make sure that everyone can participate and attend the sessions. The authors recommend replication studies with larger sample sizes in order to obtain more significant findings.

Napolitano, M.A., Llyod-Richardson, E.E., Marcus, B.H. (2011). Targeting body image schema for smoking cessation among college females: Rationale, program description, and pilot study results. Behavior Modification; 35(4): 323-346. PMID: 21502132.

The Use of Cognitive Behavioral Therapy as a Method to Improve Self Care in Medical Students

Commentary: Medical Student Distress: A Call to Action

Research has indicated that medical students tend to be more depressed than others their own age, which may have professional consequences. For example, a decline in mental health could have adverse effects on students’ levels of empathy and professionalism, and it could lead to burnout or fatigue.

A study at the Northwestern University Feinberg School of Medicine required medical students to use a cognitive behavioral approach to (1) identify a behavior they wished to improve or change, (2) monitor that baseline behavior, (3) learn about recommendations for the targeted behavior, (4) set goals for themselves, (5) implement a self-improvement plan, and (6) perform a self-assessment of effectiveness and identify factors that either promoted or hindered their goals. The types of behaviors that the students identified were related to nutrition, exercise, sleep, work/study habits, and mental/emotional health. Data was later evaluated to determine (1) whether students reached their goals, (2) what factors helped or hindered success, and (3) if the students planned to apply behavioral change techniques in the future.

Results of this study indicate that just 2.6% of the students chose to focus on direct improvement of their mental/emotional health. This may be attributed to confidentiality concerns or the inexact nature of measuring improvement in this area. Following participation, however, 80% of the students felt they were healthier as a result of completing this cognitive behavioral exercise. Students also showed insight into what factors helped and hindered achievement of their goals, and more than 80% indicated that they would be inclined to use a cognitive behavioral approach to address problems in the future.

CBT has shown to be useful in helping medical students develop skills necessary to assess personal well-being and maintain solid health habits throughout their lives. By maintaining their own health via self-care methods, medical students will hopefully be able to provide better care to their patients.

Dyrbye, Liselotte N. and Shanafelt, Tait D. (2011). Commentary: Medical Student Distress: A Call to Action. Academic Medicine, 86, 801-803.

Beck Institute Scholar Meets with Dr. Aaron Beck

Marcus Huibers, Ph.D., a former Beck Institute Scholar, visited us last week. He has conducted important research in the field of Cognitive Therapy and Depression in the Netherlands and followed up his visit with this message:

When I was first invited to become a Beck Institute Scholar in June 2006, I initially thought someone was pulling a prank on me. It was late at night when I received the email from Drs. Aaron T. Beck and Judith Beck, inviting me for the extramural training program in Philadelphia for the upcoming academic year, and it felt like I had just won the lottery. At that time, I was an assistant professor at Maastricht University, fortunate to have been awarded three large research grants in the previous years, but also struggling with the responsibilities that came along with it and the theoretical directions my work was about to take. The year before, I had met Dr. Steven Hollon for what turned out to be the start of a long and fruitful collaboration on depression research in the Netherlands, and he had nominated me for the Scholarship, which in itself was a great honor. The academic year that followed (2006-2007), I visited Philadelphia three times on overseas trips that were a tremendous learning experience, and great fun at the same time. I felt I already was a pretty good cognitive therapist, but coming to Philadelphia made me realize there was so much more I could learn on the art and wonders of state-of-the-art cognitive therapy. Not surprising, of course, since it was the founder of cognitive therapy that stood in front of the classroom to pass on his infinite knowledge.

I learned so much, talking (and even role playing) with Dr. Beck, but also from Judy Beck and Leslie Sokol, my all-time favorite CT supervisor. It also opened up the (international) world of CT research for me, with many new friends and colleagues I made during my many stays in Philly, the undisputed CT capital of the world. Since then, the depression research program we are doing in the Netherlands has expanded, with treatment studies on Internet CT, CT and interpersonal therapy (IPT), CT and behavioral activation, schema-focused therapy for chronic depression, mechanisms of change studies and experimental lab studies on cognitive theory in depression., This month, I am on a ‘mini-sabbatical’ visiting with Dr. Robert DeRubeis at the University of Pennsylvania, another one of my ‘heroes’ in the field of cognitive therapy. It has been so great to interact with Rob, his students and colleagues at the Department of Psychology, and meet Dr. Beck, Judy and many others at the Beck Institute again. Coming back here, I realize what a strong impact the Beck Institute Scholarship has had on my professional career as a researcher and therapist, and I am very grateful for that. My time at the Beck Institute has been most rewarding, and I can recommend the training program to anyone who is interested in CT. Here is where you learn from the best.

Marcus J.H. Huibers, PhD,
Professor of Empirically Directed Psychotherapy
Chair of the Department of Clinical Psychological Science
Maastricht University
The Netherlands

Cost-Effectiveness and Clinical-Effectiveness of Combined Therapy versus Medication Only in Adolescents with Resistant Major Depression

Depression in adolescents is a significant issue. Research has focused on treating major depression in adolescents with psychotherapy (CBT), medication (selective serotonin reuptake inhibitors, SSRIs), or a combination of both.  As treatment is not inexpensive, researchers have been looking into the cost-effectiveness of different treatment models.  Previous research has shown that CBT treatment and medication is the most expensive treatment model in the short run.  The least expensive model is medication only.  However, some adolescents do not respond to medication alone.

A recent randomized trial was published in the Archives of General Psychiatry. 334 adolescents with SSRI-resistant depression, were randomly assigned to one of two groups for 24 weeks: a change in medication or a change in medication plus CBT.   Throughout the treatment they were assessed at 6, 12, and 24 weeks for symptom changes, depression-free days, and depression-improvement days.  The researchers also examined the clinical outcomes within certain subgroups of participants: patients with histories of abuse, comorbid disorders, and levels of hopelessness.

The study found that using a combined treatment of CBT and medication led to more depression-free and depression-improved days.  It worked best for patients without a history of abuse or with low levels of helplessness.  While the combined treatment was more costly in the short-run, it may be most cost-efficient in the long run.  This study demonstrates the benefits of further examining the use of combined treatment in adolescents with SSRI-Resistant Depression.

Lynch, F. L., Dickerson, J. F., Clarke, G., Vitiello, B., Porta, G., Wagner, K. D., … Brent, D.  (2011). Incremental cost-effectiveness of combined therapy vs medication only for youth with selective serotonin reuptake inhibitor – resistant depression.  Arch Gen Psychiatry, 68 (3), 253-262.

The Effectiveness of Evidence-Based Treatment in Combating Multiple Anxiety Disorders

researchlogo72x65bl-new.jpgA recent study published in The Journal of the American Medical Association compared the effectiveness of Evidence-Based Treatment against usual care for multiple types of anxiety disorders.  The participants consisted of 1004 patients with varying anxiety disorders including panic, generalized anxiety, social anxiety, and post-traumatic stress disorder in 17 primary care clinics in 4 US cities.The researchers used a Brief Symptom Inventory (BSI) to measure both anxiety and somatic symptoms.  These initial scores were compared with follow-up measurements taken after 6, 12 and 18 months of either Coordinated Anxiety Learning and Management (CALM) or usual care.

The CALM model allowed participants in the intervention group to choose between Cognitive Behavior Therapy (CBT), medication alone, or CBT combined with medication. Real-time web-based outcomes monitoring was also incorporated to optimize treatment decisions, as well as a computer-assisted program to optimize the delivery of CBT.

Results showed that CALM techniques were significantly more effective than usual care in reducing global anxiety symptoms.  Patients undergoing CALM treatment had significantly reduced scores on the Brief Symptom Inventory.  These patients also had higher response and remission rates.   Response was defined as at least a 50% reduction on the BSI or meeting the definition of remission.  Remission was defined as an anxiety score between none and mild.

The results of this trial illustrate the effectiveness of Evidence-Based Treatment, specifically Coordinated Anxiety Learning and Management in real-world practice settings. CALM proved to be more effective than usual care for multiple types of anxiety disorders.  This trial indicated that Evidence-Based Treatment may be of greater help to patients with anxiety disorders than those measures currently being used.

Roy-Byrne, P., Craske, M. G., Sullivan, G., Rose, R. D., Edlund, M. J., Lang, A. J., Bystritsky, A., Welch, S. S., Chavira, D. A., Golinelli, D., Campbell-Sills, L., Sherbourne, C. D., & Stein, M. B.  (2010).  Delivery of evidence-based treatment for multiple anxiety disorders in primary care.  The Journal of the American Medical Association, 303, 1921-1928.